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Uses. For most of the twentieth century drug addiction and heroin were synonymous in the United States; all substance abuse was assumed to lead to heroin. Only in the 1980s did heroin become displaced as the devil drug, supplanted in public fear and disapproval by cocaine. Being a Schedule I substance, heroin has no officially approved medical use in the United States.

Heroin is produced from morphine, and body chemistry converts a heroin dose back into morphine. Most users cannot detect a difference between those two substances. Depending on means of administration and the effect being measured, heroin is 1.5 to 8.0 times stronger than morphine and is used medically to suppress coughs and relieve pain in children and adults. One study of pain relief found heroin comparable to hydromorphone, a standard medication administered to fight severe pain. Physicians have judged heroin to be a safe anesthetic for use during childbirth, with no apparent ill effect on mother or child. The drug is also used to treat porphyria, a body chemistry disorder making people sensitive to light and occasionally making them violent. Heroin users of both genders have reported increased sexual activity upon starting the compound, with decline in that activity as usage continues. That sequence would be consistent with the drug at first reducing psychological anxiety, an effect gradually evolving into indifference about the world. As noted below, heroin has hormonal actions that reduce male sexual activity.

Extrapolating from severity of withdrawal symptoms, any particular size heroin dose taken by intravenous injection is five times stronger than one taken by inhaling heated vapor ("chasing the dragon"). Other measurements show a dose to be four times more potent when taken intravenously instead of by inhaling powder.

Sometimes intravenous injection of heroin produces a rush of feeling likened to a total body sexual orgasm. Heroin may allow some nonmedical users to experience euphoria, but more typically an intoxicating dose increases psy chic distance between the user and the world, making reality seem unimportant. Used in that way the drug is an escape—not into happiness but into emptiness. Someone intoxicated by a dose of heroin does not care what happens any more. Lesser doses simply reduce tension, taking the edge off life's stresses. People using lesser doses of heroin in that way may function more productively, or they may experience trouble because they feel confident enough to get into situations they would otherwise avoid.

Drawbacks. Classic unwanted heroin actions are nausea, vomiting, and constipation. Many other afflictions attributed to the drug actually come from adulterants in illicit supplies or from dosage techniques—such as addicts sharing the same hypodermic needle with one another, a custom promoting diseases ranging from hepatitis to AIDS (acquired immunodeficiency syndrome). Researchers find, however, that injectors of a heroin variety called "black tar" have an increased risk for botulism infection at the injection site, no matter how hygienic their equipment and technique. Injectors of any type heroin are more prone to all sorts of infections, and some researchers suspect that heroin impairs the immune system. Inhaling heated heroin vapor can rapidly produce enough brain damage to cripple a person, although case reports indicate that partial recovery is possible. Inhaling either the vapor or powder can also cause breathing trouble, and injection can cause swift fluid buildup in the lungs. A study found reduced bone density in chronic male heroin users, making broken bones more likely, and researchers suspected the problem resulted from lower testosterone levels caused by heroin (a heroin action that is also known to reduce male sex drive). Apparently the bone density and testosterone problems can correct themselves if heroin use stops. Although stroke is an uncommonly reported outcome of heroin use, autopsy examinations of 100 heroin addict brains indicate that 5% to 10% of injectors suffer small strokes that may not cause the person to seek medical treatment but that may thereafter affect the person's behavior. One experiment with heroin addicts found still another unwanted effect: Most of them see colors somewhat differently than nonusers do.

Abuse factors. All the above hazards are real, but experience also shows that addicts can take maintenance doses (enough to hold off withdrawal symptoms but not enough to get high) for years with no apparent ill effect. The behavior of people on a maintenance dose can be indistinguishable from someone using no drug at all; while on a maintenance dose of heroin ordinary middle-class persons can function well in all aspects of life at work and at home.1 Such factors are highly influenced by the legal setting of heroin use. When federal legislation outlawed the drug in the early twentieth century, the kinds of persons who took the drug changed, as did the common reasons for using the drug.

Achieving heroin addiction is normally a lengthy process; people do not become addicts instantly with a single dose. Indeed, persons can use heroin intermittently for years and not develop dependence, let alone develop a compulsion to take the drug. Someone with a fulfilling life is unlikely to become addicted even if heroin is used occasionally. In contrast, people with nothing to live for may find heroin to be the best part of their lives, a discovery leading to addiction.

Breaking heroin addiction depends on the reason someone takes the drug. Severe withdrawal symptoms mimic influenza, but someone willing to put up with them for a couple of days can emerge with no more dependence on the drug. Physical dependence with heroin is a relatively trivial part of addiction. Few addicts take the substance simply to avoid the withdrawal syndrome. Instead, they take the drug to cope with assorted frustrations in life. If those frustrations are resolved, the heroin addiction will resolve. If those difficulties remain, heroin may remain the best way the addict knows to cope with them, and addiction will persist.2 Both heroin and tobacco can reduce stress, and if heroin users cut back on that drug, they often increase their cigarette consumption.

Although heroin is traditionally considered the final step in illicit drug use, with previous substances leading from one to another until the climax of heroin is reached, scientific research does not support that scenario. Experienced drug users have typically used assorted substances over the years, but the "gateway" hypothesis in which one substance leads to another has been refuted time and again. Nor is heroin necessarily the final stopping place for addicts. For example, research demonstrates that some heroin users move on to amphetamines as their main drug.

Drug interactions. Some persons use heroin and amphetamines together or heroin and cocaine together, a potentially fatal practice called speedballing, in order to get a variety of simultaneous drug sensations. Analysis of fatalities attributed to heroin suggests that alcohol increases risk of death.

Cancer. Whether heroin can cause cancer is unknown. One study found that cells of heroin addicts show chromosome damage that might promote cancer, but the damage becomes less over a period of months if addicts switch from heroin to methadone. Other research has found that intravenous heroin users are more likely to get cancer than the general population, but factors other than heroin may be involved.

Pregnancy. Although heroin usage apparently damages chromosomes, the damage may be from breakdown products rather than heroin itself. A study of several dozen infants found that those from heroin-using mothers had six or seven times the amount of chromosome damage found in infants from mothers who did not use the drug. This damage did not translate into congenital malformations, however. Researchers have examined children born to women who abused heroin during pregnancy and found no indication that the drug causes birth defects. Infants may be smaller than normal upon birth, but heroin's role is uncertain because the women tend to abuse additional drugs and engage in other conduct harmful to fetal development. Infants born to such mothers may have dependence with heroin and undergo withdrawal symptoms. Sudden infant death syndrome is more common in babies with fetal exposure to heroin than in babies without any illicit drug exposure, but researchers are uncertain whether the drug is a more important factor than overall home environment. Physical and mental development of children whose mothers used heroin during pregnancy is slightly slower than normal, an observation supported by findings in rat experiments. Examination of school-age boys who had fetal exposure to heroin finds them to be much like other children despite lower scores on various physical and psychological tests; one group of researchers noted that prenatal exposure to alcohol has much more impact than heroin, and another investigator noted that girls' test scores were normal.

Among pregnant Australian women in drug treatment programs who use both heroin and methadone, infant mortality is higher than among women who only use methadone, but researchers believe the difference is not due to heroin but due to multiproblem lifestyles in which heroin is just one of many problems. This theme was also brought out by a study in Israel comparing children of parents who abused heroin and children of parents who did not, while at the same time comparing home environments. The investigators discovered that assorted problems suffered by children of heroin users had much more to do with general conditions at home than with any chemical influence of the drug on fetal development, a conclusion supported by still more Israeli research and consistent with findings by the U.S. National Institute on Drug Abuse and other researchers.

Breast-feeding by heroin-using mothers is considered safe for their infants. Passage of heroin into the milk is doubtful, and levels of heroin's breakdown products (such as morphine) are low enough to avoid hazard.

Additional scientific information may be found in:

Cygan, J., M. Trunsky, and T. Corbridge. "Inhaled Heroin-Induced Status Asthmaticus:

Five Cases and a Review of the Literature." Chest 117 (2000): 272-75. "Diamorphine." In Therapeutic Drugs, ed. C. Dollery. 2d ed. New York: Churchill Livingstone, 1999. D70-D75. Ornoy, A., et al. "The Developmental Outcome of Children Born to Heroin-Dependent Mothers, Raised at Home or Adopted." Child Abuse and Neglect 20 (1996): 385-96. Sawynok, J. "The Therapeutic Use of Heroin: A Review of the Pharmacological Literature." Canadian Journal of Physiology and Pharmacology 64 (1986): 1-6. Schneider, J.W., and S.L. Hans. "Effects of Prenatal Exposure to Opioids on Focused Attention in Toddlers during Free Play." Journal of Developmental and Behavioral Pediatrics 17 (1996): 240-47. Sneader, W. "The Discovery of Heroin." Lancet 352 (November 21, 1998): 1697-99. Zuckerman, G.B., et al. "Neurologic Complications Following Intranasal Administration of Heroin in an Adolescent." Annals of Pharmacotherapy 30 (1996): 778-81.

Notes

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Judgment (New York: The Free Press, 1970), 9, 117-28, 241; C.W. Earle, "The Opium Habit: A Statistical and Clinical Lecture," Chicago Medical Review 2 (1880): 445; L.S. Goodman and A. Gilman, The Pharmacological Basis of Therapeutics, 2nd ed. (New York: The Macmillan Company, 1955), 242-44; N. Hentoff, A Doctor Among the Addicts (Chicago: Rand McNally, 1968), 43-44; L. Hutchins, et al., "A Two-Year Follow-Up of a Cohort of Opiate Users from a Provincial Town," British Journal of Addiction 66 (1971): 129-40; Jaffe, "Drug Addiction and Drug Abuse," in Goodman and Gilman, Pharmacological 7th ed. (1985), 542, 547; Jaffe and Martin, "Opioid Analgesics and Antagonists," in Goodman and Gilman, Pharmacological 7th ed. (1985), 498; L. Johnston, Drugs and American Youth (Ann Arbor, MI: Institute for Social Research, University of Michigan, 1973), 193, 218; J. Kaplan, The Hardest Drug: Heroin and Public Policy, Studies in Crime and Justice (Chicago: University of Chicago Press, 1983), 136; R. King, The Drug HangUp: America's Fifty Year Folly (New York: W.W. Norton & Company, 1972), 18, 76; L. Kolb, Drug Addiction: A Medical Problem (Springfield, IL: Charles C. Thomas, 1962), 1011, 46, 57-58, 64, 104-5, 114; Mellinger et al., "Drug Use, Academic Performance, and Career Indecision: Longitudinal Data in Search of a Model," in D.B. Kandel, ed., Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues (Washington, DC: Hemisphere Publishing Corporation, 1978), 167-69, 172-73; H.W. Morgan, Drugs in America: A Social History, 1800-1980 (Syracuse, NY: Syracuse University Press, 1981), 31; H.W. Morgan, Yesterday's Addicts: American Society and Drug Abuse 1865-1920 (Norman: University of Oklahoma Press, 1981), 8; E.J. Morhous, "Drug Addiction in Upper Economic Levels: A Study of 142 Cases," West Virginia Medical Journal 49 (July 1953): 189; J.A. O'Donnell, Narcotics Addicts in Kentucky, U.S. Public Health Service Publication No. 1881 (National Institute of Mental Health, 1969) [SuDocs FS2.22:N16/3], 56, 60, 7980, 94-98, 204, 211, 214, 217, 223-33, 241; S. Peele, with A. Brodsky, Love and Addiction (New York: Taplinger Publishing Company, 1975), 35; J.J. Platt and C. Labate, Heroin Addiction: Theory, Research, Treatment, Wiley Series on Personality Processes, A Wiley Interscience Publication (New York: John Wiley & Sons, 1976), 171; H.G. Pope, Jr., M. Ionescu-Pioggia, and J.D. Cole, "Drug Use and Life-Style among College Undergraduates: Nine Years Later," Archives of General Psychiatry 38 (1981): 588-91; C. Raymond, "Researchers Say Debate over Drug War and Legalization Is Tied to Americans' Cultural and Religious Values," Chronicle of Higher Education 36 (March 7, 1990): A6-A7, A10-A11 (Craig Reinarman comments); "Report of Committee on the Acquirement of Drug Habits," Proceedings of the American Pharmaceutical Association 51 (1903): 473; J. Rublowsky, The Stoned Age: A History of Drugs in America, Capricorn Books (New York: G.P. Putnam's Sons, 1974), 138, 191; E.M. Schur, Narcotic Addiction in Britain and America: The Impact of Public Policy (Bloomington: Indiana University Press, 1962), 28, 151; G.V. Stimson, Heroin and Behaviour: Diversity among Addicts Attending London Clinics (New York: John Wiley & Sons, 1973), 149, 178; G.M. Smith, C.W. Semke, and H.K. Beecher, "Objective Evidence of Mental Effects of Heroin, Morphine and Placebo in Normal Subjects," Journal of Pharmacology and Experimental Therapeutics 136 (1962): 53, 58; A.S. Trebach, The Great Drug War and Radical Proposals That Could Make America Safe Again (New York: Macmillan Publishing Company, 1987), 345; U.S. Congress, House, Select Committee on Crime, Hearings, The Improvement and Reform of Law Enforcement and Criminal Justice in the United States (91 Cong., 1 sess., 1969) [SuDocs Y4.C86/3:L41], 287, 291 (Stephen Waldron statement); U.S. Congress, Senate, Committee on the Judiciary, Subcommittee on Improvements in the Federal Criminal Code, Hearings, Illicit Narcotics Traffic (84 Cong., 1 sess., 1955) [SuDocs Y4.J89/2:N16/1-10], 1326, 1339 (Hubert S. Howe testimony); A. Weil, The Natural Mind: An Investigation of Drugs and the Higher Consciousness, Rev. ed. (Boston: Houghton Mifflin Company, 1986), 55, 57-58; White House Conference on Narcotic and Drug Abuse, Proceedings (1962) [SuDocs Y3.W58/5:2P94/962], 305; N.E. Zinberg, Drug, Set, and Setting: The Basis for Controlled

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